House Speaker Nancy Pelosi of Calif. speaks during a news conference on Capitol Hill in Washington, Thursday.

Jose Luis Magana/AP

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Washington

Two days after the Massachusetts miracle that gave Republicans their 41st vote in the Senate, Democrats are in intense negotiations – mainly within their own ranks – over how to move forward on healthcare reform.

For much of the debate, the focus has been on Senate majority leader Harry Reid, who personally negotiated the deals to win over the critical 60th vote in the Senate. But with Republican Scott Brown’s victory, the heavy lifting on healthcare shifts back to House Speaker Nancy Pelosi: Can she win over enough Democratic votes in the House to pass the Senate’s version of the bill?

“Without any change, I don't think it is possible to pass the Senate bill in the House,” she said at a briefing today.

Healthcare fast track derailed

That vote count – by a Speaker noted for being good at it – derails what had been the fastest track to moving healthcare through the Congress. Passing the Senate bill as written avoids further action in the Senate, where Democrats no longer have the 60 votes needed to block a Republican filibuster.

Democrats are in agreement on about 80 percent of policy, she said. There is also broad agreement among Democrats in both the House and Senate that Congress must pass healthcare legislation. “We have to get a bill passed. We know that, that is predicate that we all subscribe to. We have to pass legislation,” said Pelosi.

But new outreach to Republicans is not on the agenda. Pelosi says that hearings were held in three House committees, and that some GOP amendments were adopted. “But [Republicans] have made it clear that they are not for healthcare reform, and we are,” she said.

There are elements in the Senate bill that are unacceptable to House Democrats, Pelosi said. Exhibit A is a provision, negotiated by Sen. Ben Nelson (D) of Nebraska, to exempt his state from paying the costs of expanding Medicaid coverage.

“What [House Democrats] would want to see fixed is that there be equity among states, more fairness, and that that policy shouldn’t be made on the basis of one senator,” she said.

Another stumbling block for House Democrats is the taxation of high-benefit healthcare plans, including those negotiated by trade unions. Last week, President Obama and union leaders worked out a compromise that would exempt unionized workers from the new excise tax, dubbed “Cadillac tax,” until contracts are renegotiated. To pass the Senate bill without that fix is unacceptable, Pelosi said.

Before Tuesday’s election, Congress appeared to be just a deal-or-two away from passing President Obama’s top domestic priority. On Wednesday, the president proposed that Democrats consider scaling down the legislation to pass elements that enjoy broad support, such as rules barring insurance companies from discriminating on the basis of preexisting conditions or canceling a policy when the policyholder becomes ill.

While welcoming the suggestions, Democrat leaders say that legislation in both the House and Senate involved critical trade-offs that could be lost if only the most popular elements are preserved.

“Well, I don't think anybody disagrees with, ‘Let's pass the popular part of the bill,’ but some of that popular part of the bill is the engine that drives some of the rest of it,” Pelosi said.

Responding to the same question, Senate Finance Committee chair Max Baucus (D) of Montana, says that carving up the bill to pass only the popular elements could undermine the policy trade-offs that make reform feasible. “Insurance reform, for example, can work only if there also is an individual mandate requiring Americans to purchase their own insurance,” he says.